(This post is about some basics in echocardiography meant for fellows, and echocardiographers. Others can skip please )
This is a 27-year-old woman who was referred for routine* cardiac evaluation. What do you see?
What is the diagnosis?
This echo clip is from a woman who is 8 months pregnant. What you are seeing is perfectly physiologically and normal. On lying down there is a mechanical push of the diaphragm altering the LV shape and contraction. In the short axis, the left ventricle is contracting well, but the shape is not spherical in systole implying some desynchrony. Further, the IVS arena is contracting vigorously, which makes, the other segments appear to be poorly contracting. (Someone could report it as a wall motion defect in antero- lateral segments inviting temporary panic)
It is worthwhile to go through this list of non-ischemic WMA and find the pregnancy at the bottom of the list.
Few more conditions, that can be added to this list
- Though LBBB is the classical cause for WMA, we have seen even LAFB showing the bumpy motion of IVS and the anterior wall.
- Some patients with ERS and some patients with Brugada show wall motion defects due to repolarisation heterogeneity.
- Regioanl pericarditis
- Intracardiac scars. Localized fibrosis.
- Extracardiac tumors
iFAQ on this topic
Is this wall motion defect in pregnancy, really an artifact or real?
They are true artifacts in the sense, the heart is an innocent bystander in this pulsating fight between intra-thoracic vs intrabdominal pressures. A similar situation happens in ascites.
Any other mechanism other than mechanical push?
WMA due to RV volume overload of pregnancy may also contribute.
Does this WMA affect cardiac hemodynamics?
Logically it should, but it doesn’t. The normal heart has enormous resilience, it just ignores these subtle pushes from below and keeps working normally. Still, enormous distension of the abdomen especially in twin pregnancies, in small body habitus, can make some women breathless, or orthopenic. I am sure, one of the mechanisms could be this geo-mechanical encroachment.
Final message
Wall motion defects are not synonymous with CAD. There is an important list of non-ischemic conditions that can cause WMA. Cardiology fellows and echo technicians are encouraged to go through the above list one more time. While this knowledge can prevent false alarms, at the same time it is always wise to ask for the ECG before doing echocardiography, and not to miss the omnipotent CAD.
Postamble
*DIscerned readers might wonder why a routine echo was done in a normal pregnancy. I am surprised to note there is an ongoing fad in this part of the world, to do echocardiographic screening on every pregnant mother to rule out cardiovascular disease. (A luxury even the world’s richest country can’t afford) I am told, this echo is meant to rule out peripartum cardiomyopathy for legal purposes. A spot echo at term can never be going to either predict as an event that is mainly going to happen postpartum. This newfound epidemic of anxiety among obstetricians is unwarranted.
Reference
A well-written focused review specifically on this topic
Yavagal ST, Baliga VB. Non-Ischemic regional wall motion abnormality. J Indian Acad Echocardiogr Cardiovasc Imaging
2019;3:7-11.
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Dr.S.Venkatesan MD 